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Home » Web Exclusives » Prostate Cancer Management Across America

Prostate Cancer Care Rebounding After COVID-19 Disruption

Jody A. Charnow

Routine and nonessential healthcare services came to a nearly complete halt in many places

throughout the United States as a result of the coronavirus disease 2019 (COVID-19) pandemic.

Hospitals and medical practices discontinued or substantially curtailed provision of all but the most

necessary procedures. Fearing infection with the novel coronavirus that causes COVID-19, many

patients avoided contact with the healthcare system. Caseloads dropped precipitously across

physician specialties.

Physicians who manage patients with prostate cancer (PCa) have not been spared. Urologists, for

example, have had to postpone performing prostate biopsies and radical prostatectomies (RPs) except

in the most urgent cases. In interviews with Renal & Urology News, urologists and medical oncologists

across the nation explained their PCa caseloads, which plummeted for a few months early in the

pandemic, have rebounded substantially even in areas that were severely impacted by COVID-19

outbreaks.

New York City

Those hard hit places include New York City, which quickly emerged as the nation’s pandemic

epicenter. As early as April 1, for example, the city’s health department reported a total of 45,707

con�rmed COVID-19 cases and 1374 deaths. Those numbers soared to 164,505 and 13,000,

respectively, by April 30, and further swelled to 229,980 and 19,042, respectively, as of August 30.

Patients with COVID-19 overwhelmed hospitals. All but the most urgent medical procedures were

September 1, 2020

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C O N T I N U E R E A D I N G

postponed. Physicians with Integrated Medical Professionals, parent company of Advanced Urology

Centers of New York and Advanced Radiation Centers of New York, an independent group with

headquarters in Farmingdale, New York, and a clinical af�liate of The Mount Sinai Health System in

New York, New York, can attest to how COVID-19 hampered PCa care.

Prior to the pandemic, urologists in the group performed around 1000 prostate biopsies a quarter,

said urologist Deepak A. Kapoor, MD, the group’s chairman and chief executive of�cer. For a few

months after the pandemic struck, the number of these biopsies plunged to only a few per week, he

said.

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Dr Kapoor pointed out that prostate biopsies can result in sepsis, the most signi�cant complication of

the procedure, as well as bleeding and urinary retention. Patients may require hospitalization if these

problems occur. This would mean using hospital resources when they were badly needed to care for

COVID-19 patients. “As a result, we felt that it was our moral obligation to not do elective prostate

biopsies,” he explained. “As a consequence, many of those biopsies were delayed.”

However, the group is now ramping up prostate biopsies, Dr Kapoor said. He estimates that his group

is at 75% to 80% of the prostate biopsy volume they had before the pandemic. A return to normal

biopsy caseloads was delayed in part because patient anxiety about contracting COVID-19 kept

individuals from undergoing the procedure, he said. Another factor was the availability of procedure

room time “because we still try to do biopsies transperineally, our ability to do the procedure is a little

bit restricted,” Dr Kapoor related.

Dr Kapoor said his group moved quickly to establish safety protocols. During the second week of

March, the group formed a COVID-19 task force that had representatives from every specialty and

service department. “We pulled together as a team in amazing collective fashion in a very short period

of time to create protocols that would enable us to continue to function clinically while keeping our

employees and our patients safe … and most importantly, out of the hospital.”

“Our goal during the pandemic was to keep our patients out of the hospital because if you have a trip

to the hospital you’re in big trouble,” said Ann E. Anderson, MD, the group’s director of pathology. Not

only would patients be at risk of contracting COVID-19, they might not have a bed or stretcher

available to lie on, she said.

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Priorities in Prostate Cancer Care During the Pandemic

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Dr Anderson and her pathology colleagues developed a virtual laboratory methodology whereby

physicians could order laboratory tests via telemedicine. This way, patients could go to diagnostic

testing sites in their community rather than have to travel to one of the group’s of�ces.

The group was able to increase caseloads largely because of COVID-19 testing, Dr Anderson said. “We

were extremely proactive in COVID testing during the height of the pandemic for our staff,” she said.

“That was a very big boost to the staff morale and the company’s ability to provide care for the

patients.”

Longer-Duration Hormonal Injections

During the height of the pandemic in New York City, Dr Kapoor related, some patients with PCa who

were faced with postponement of RPs opted instead to have radiation therapy rather than delay

treatment. Other patients with PCa were given androgen deprivation therapy (ADT) as a stopgap

measure until they could undergo RP, Dr Kapoor said. For patients with advanced PCa, urologists gave

6-month, rather than 3-month, injections of hormonal therapy to increase the interval between

patient visits. The only patients with PCa for whom care changed little during the pandemic were

those with castration-resistant disease. As they are high-risk patients, “we had no choice but to bring

them in on a regular basis to make sure they were adequately followed,” Dr Kapoor said.

Telehealth played a big part in cutting down on the number of face-to-face encounters with patients,

he said. His group went from having no telehealth encounters on March 12 to nearly 2000 telehealth

encounters a week by the end of March. “I don’t know what we would have done had we not been able

to at least communicate with those patients virtually,” he said.

The expanded use of telehealth was enabled in large part by the Centers for Medicare and Medicaid

Services (CMS), which issued waivers that gave greater �exibility in the use of this modality and

established payment parity between telehealth and regular in-person clinical care for Medicare

patients.

‘Semblance of Normalcy’

UroPartners, LLC, a large urology group practice that serves the Chicago area, experienced a 70%

decline in patient visits early during the pandemic, but the situation has improved substantially, said

the group’s president and chief executive of�cer, Richard Harris, MD, who also is president of the

Large Urology Group Practice Association (LUGPA). In-of�ce visits bounced back much faster than he

expected, he said. “We’re back up to 98% of our pre-COVID numbers,” Dr Harris explained, adding that

his group �gured out how to work around the dif�culties posed by the pandemic so they could keep

everybody safe while providing care. He credits telehealth for enabling providers in his group to “stay

in the loop” with many patients. “The ability to do telemedicine has had a profoundly positive impact

on our ability to treat these patients,” Dr Harris said.

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Dr Harris said his group’s surgicenter is handling more cases than ever because many patients do not

want to undergo procedures in a hospital for fear of COVID-19. As elsewhere, RPs were put off for a

couple of months, but the number of these procedures began rising around May or June.

“I think most people are getting back up to speed as far as patient care,” said Dr Harris. “It’s not quite

business as usual. I don’t know that it’s ever going to be until we have a vaccine or this [virus] has gone

away. But at least we’re back to some semblance of normalcy.”

Paci�c Northwest

PCa care also appears to be rebounding in the Washington State and the Paci�c Northwest in general,

according to Daniel W. Lin, MD, professor and chief of urologic oncology at the University of

Washington in Seattle, where he also is director of the Institute for Prostate Cancer Research. The

COVID-19 outbreak in Washington State — which had 74,320 con�rmed COVID-19 cases and 1905

related deaths as of August 30 — was not as severe as in New York City, but during the height of the

outbreak from mid-March to the end of April the “center basically stopped doing biopsies for routine

elevated PSA,” Dr Lin explained. The same was true for most, if not all, of the Paci�c Northwest.

“Patients, we think, probably were not hurt by a few-month delay,” he said.

Discontinuation of prostate biopsies for several months, however, has led to a decline in new PCa

diagnoses, he noted.

There was a period of a few months when many hospitals nationwide were discouraging or postponing

surgeries and radiation therapy for lower-risk PCa, not only to protect patients and staff from COVID-

19 transmission, but also out of concern about running out of PPE and other resources that might be

needed for live-saving COVID-19 care. At the University of Washington, some robotic RPs for low-risk

PCa were postponed because of concern about using up resources.

Still, patients have been reluctant to make medical visits, and this has devastated primary care

practices, according to Dr Lin. “Patients are fearful of seeing their healthcare provider. They are not

seeking general medical care, and thus are not getting screened for prostate cancer.” This fact has led

to a decrease in patient referrals to urologists because of elevated PSA.

Even though Oregon, another Paci�c Northwest state, had a relatively mild COVID-19 outbreak (with

26,554 and 458 con�rmed cases and deaths as of August 30 ) compared with New York City and some

other cities, COVID-19 altered medical care.

“We had a statewide halt on nonessential medical procedures that ended on May 1,” said medical

oncologist Tomasz M. Beer, MD, professor of medicine at the Oregon Health & Science University

(OSHU) in Portland, where he is deputy director of the OHSU Knight Cancer Institute. “During that

time, prostate biopsies and even prostatectomies except for very aggressive cases were viewed as

nonessential cases. But medical treatment for advanced cancer was universally treated as essential.

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We did not delay any hormonal therapy or chemotherapy or immunotherapy. And we did not delay

participation and treatment in clinical trials. We were able to continue most of our clinical research.”

Routine visits for prostate cancer screening had largely been put on hold during March through May,

and even men with elevated PSA may have delayed seeing urologists to arrange for a biopsy, Dr Beer

said. Men who had a low-grade cancer found on a prepandemic biopsy may have held off on treatment

because they know there generally is no urgency with these tumors. But caseloads are essentially back

to what they were before the pandemic. “We’re all real busy again now,” he said.

Physicians at the institute transitioned many patient encounters to a virtual setting, Dr Beer said. “We

see a lot of our patients by video [or] by phone if they have no access to video. But if they need

injections or infusions or imaging or blood tests, we have facilities set up to accommodate that, and

they’ve continued to receive their treatment as scheduled.”

As a result of the COVID-19 crisis, Dr Beer explained that physicians made adjustments in speci�c PCa

treatments. For example, during the pandemic, most patients on hormonal therapy were switched to

6-month injections from 1-, 3-, and 4-month injections to decrease the number of patient visits.

Miami-Dade County

In one of the newest COVID-19 hotspots, Florida’s Miami-Dade County (which as of August 30 had

156,038 and 2399 con�rmed COVID-19 cases and deaths, respectively ), the outbreak prompted

changes in how physicians at Sylvester Comprehensive Cancer Center in Miami provided PCa care as

early as April.

“For a couple of weeks to a month beginning around mid-April, everything almost shut down

completely,” said urologic oncologist Sanoj Punnen, MD, associate professor of urology at the

University of Miami’s Miller School of Medicine. “We’ve had to restructure a lot of what we do.”

Prior to the pandemic, he saw patients from 8 AM to 5 PM, but now he sees them from 8 AM to noon,

with priority given to patients he “really needs to see in person for any acute issues and procedures.”

Clinic staff schedule appointments to ensure patients do not wait around with others. Patients wait in

their cars until they receive a phone call telling them a clinic room is available for their appointment.

His afternoons in clinic are spent conducting telehealth visits for patients he does not need to see in

person. As a result of how his clinic functions, patients generally do not experience delays in care, he

said. “If a patient needs a biopsy, he can get it done pretty much as [if] we were at full capacity,” Dr

Punnen said.

A Busy Period for Medical Oncologists

Even in Minnesota, which was not especially hard hit by the pandemic, physicians had to alter their

usual care of patients with PCa as a precaution, notably in March and April, according to Arpit Rao,

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MBBS, an assistant professor in the Division of Hematology, Oncology and Transplantation at the

University of Minnesota in Minneapolis. Dr Rao leads the genitourinary oncology clinical research

program and the oncology quality and safety team for M Health Fairview system. According to Dr Rao,

some patients facing delayed RP or radiation therapy were placed on a few months of ADT as a

therapeutic bridge until they could receive de�nitive treatment. The medical oncology department

became busier during the pandemic, Dr Rao said, a trend he suspects is due in part to postponed PCa

surgeries. Given the delay, men sought consultations with medical oncologists “just to make sure

they’re exploring all the options,” he said.

“Before the pandemic, we had probably 16 to 20 patients in a day of clinic,” Dr Rao said. “During the

pandemic, the volume has been 20% to 30% higher.”

For patients with metastatic PCa, he took steps to space visits farther apart when the pandemic hit. “I

used to see everybody about once a month for oral novel antiandrogen therapy; now I see them every

6 to 8 weeks at this point,” Dr Rao said. “Whereas we used to get imaging every 3 months, now it’s

every 4 to 6 months. Whether that’s going to have long-term consequences remains to be seen. But in

the short term, we haven’t really experienced any signi�cant increases in complication rates.” For some

patients already on ADT, he switched from 3-month to 6-month injections to decrease the number of

patient visits.

Surgeries Resume ‘At Full Pace’

Although the pandemic led to an RP backlog, the situation has begun to normalize, according to Dr

Rao. “We have been able to resume surgeries at full pace, as before the pandemic,” he said.

He kept in touch with many patients via telehealth, which he found useful but not optimal in some

cases. “After the pandemic started, 80% of our visits were virtual,” he explained. “The pandemic

offered us a glimpse into the future of oncology care and allowed us to understand the characteristics

of patients and services that can be safely and effectively transitioned to a telehealth model, and of

those for whom the traditional care model would continue to be the best approach.”

Telehealth is a major part of how City of Hope, a comprehensive cancer center in Duarte, California, is

managing patients with PCa during the pandemic. “COVID-19 has led many patients to be hesitant to

come see their doctors due to perceived fear of exposure to the novel coronavirus,” said medical

oncologist Yung Lyou, MD, PhD. As a result, patients undergoing chronic PSA surveillance or who were

not on any active treatments that require a clinic visit — such as leuprolide injections or chemotherapy

infusions — have asked to be converted to telehealth encounters.

“While City of Hope had a telemedicine program prior to the pandemic, the current situation

prompted us to rapidly accelerate our planned telemedicine program expansion,” he said.

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Reassuring Patients by Phone

Increased use of telehealth was just one of the effects of the COVID-19 outbreak. Dr Lyou said he had

to reassure patients by telephone that his institution had strict infection-control measures in place to

prevent COVID-19 transmission. “Many of my patients have felt anxious,” he said, “so I have had to

make quite a few phone calls to inform them that at City of Hope, where the focus is primarily cancer

patients, we take very strict precautions to limit the spread of COVID-19 within our facility. For

example, I detail how all staff and patients are screened with a detailed questionnaire and

temperature check prior to admission into the cancer center. Also, everyone is required to wear a

mask and if they show up without one, we will issue a medical grade facemask at the door.”

Dr Lyou said physicians and other staff at City of Hope have been fortunate in that their leadership has

maintained adequate levels of personal protective equipment (PPE) for everyone. Additionally, drive-

through COVID-19 testing is readily available on the Duarte campus, with an approximately 4-hour

turnaround time. “We perform in-house COVID-19 screening prior to all surgical procedures or

hospital admissions,” Dr Lyou said. “These measures have greatly helped to limit our COVID-19

infection rates.”

To lower the risk of COVID-19 transmission, the City of Hope medical center limits the number of

visitors. “In the pre-COVID era, we used to see patients with their family members or caregivers,” he

said. “However, due to COVID-19 visitor restrictions, with few exceptions, only the patient is allowed

to enter the clinic for visits. As a workaround, we have been using telephone or videoconferencing

with the other family members while we see patients to ensure everyone is included in the medical

decision making [process].”

Dr Lyou said he has had to educate patients with PCa about their risk of contracting COVID-19. One

of the most common questions I get asked is, ‘As a prostate cancer patient, do I have a higher risk for

COVID-19 compared to the general population?’”

He informs patients on chemotherapy that they may be at higher risk for infection because their

treatment causes myelosuppression, but explains to ADT recipients that no de�nitive evidence exists

showing that ADT causes immunosuppression. “As a result, they are most likely at the same risk as

someone in their age group without prostate cancer,” he said.

Rami�cations of Delayed Care

Whether the delays in care caused by the pandemic will have an effect on PCa outcomes is unclear.

Urologists and oncologists generally agree that deferring such medical procedures as prostate

biopsies and prostate surgery for a few months will likely have no signi�cant effect on oncologic

outcomes in patients with low-risk PCa. As Dr Kapoor pointed out, PCa is generally a slow growing

cancer compared with other genitourinary malignancies. “Frankly, I am much more worried about my

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patients with renal cell carcinoma and my patients with bladder cancer who may not have been able to

come in than I am worried about the patients with prostate cancer,” he said.

Nevertheless, he said, “It would be naive to believe that there were some patients whose pathology

didn’t advance.”

Although the pandemic interrupted routine follow-up care such as PSA tests and prostate biopsies for

patients on active surveillance, Dr Harris said, most of these patients have low- or very low-risk

cancer, “so a month or two probably isn’t going to make any difference as far as outcomes or changes

in their disease pattern.”

Dr Punnen observed that patients with PCa usually do not need acute care, even those with

metastatic disease on ADT. “If they miss receiving their ADT injection by a month or so, “it’s probably

not going to have a huge impact,” Dr Punnen said.

Dr Rao pointed out, however, that many men are skipping primary care visits and not having PSA tests

that could detect subclinical PCa. “They may end up presenting with locally advanced disease,” he said.

Men with advanced PCa and asymptomatic bone metastases, especially those with aggressive disease,

may progress to symptomatic disease and present with cancer-related complications as a result of

putting off follow-up care for a few months, he said.

Prostate Cancer Research

As with patient care, the pandemic has had an effect on PCa research, but to varying degrees across

the United States. At the Sylvester Comprehensive Cancer Center, clinical research slowed “because

obviously research isn’t given the same priority as clinical care,” Dr Punnen said. Many research

coordinators are still working from home, and that has had an impact on clinical trial accrual. “We

don’t really have the resources to get [patients] enrolled in trials and follow through with care,” Dr

Punnen said. “As a result, I don’t think we’re seeing the accruals that we normally would.” He added,

however, that the situation is “getting better week by week, and we’re almost back to where we used

to be.”

The pandemic curtailed much of the PCa research at the University of Washington, which had to

suspend a number of clinical trials because of concern about exposing patients to the COVID-19

coronavirus, Dr Lin said. These studies included dose-�nding phase 1 trials and phase 3 trials where a

“nonexperimental equivalent” treatment is available, he said. One of these phase 3 trials is SWOG

1802, which is being conducted at sites throughout the United States. The trial is comparing standard

systemic therapy alone (the nonexperimental equivalent) with standard systemic therapy plus

de�nitive treatment (RP or radiation) of the primary tumor (the experimental therapy) in patients with

metastatic PCa.

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The pandemic has had less of an effect on clinical research at OSHU. “By and large, we were able to

both continue to treat patients on study and continue new enrollments into treatment studies,” Dr

Beer said. Investigators discontinued some non-treatment studies in which there was no clear bene�t

to patients. Earlier in the pandemic, they stopped projects that involved gathering patient samples

solely for laboratory research and had no direct effect on patient care, but these projects have since

resumed, he said.

At the University of Minnesota, COVID-19 had minimal effect on PCa research, according to Dr Rao. “I

think we’ve been very successful at keeping the pace of clinical research going,” he said, adding that his

institution’s research program has actually grown in terms of enrollment.

“We’ve been able to publish, we’ve been able to contribute to [U.S. Food and Drug Administration]

approvals despite the pandemic,” Dr Rao said. “But there have been challenges. At one point, we were

basically doing twice as much paperwork to get every single enrollment. Enrollments were halted

university-wide, and you had to convince 3 tiers of research personnel to get a patient into a clinical

trial.”

He added, “Our patients have been very committed to clinical research. Many of them have been

committed knowing full well that the research could bene�t future patients. That’s altruism at its

�nest.”

Regardless of COVID-19 outbreak severity, the pandemic has forced physicians in many parts of the

United States to cut back substantially on PCa-related procedures at least for a few months, resulting

in a backlog of cases. The situation appears to be brightening, however. Even in places hard hit by

COVID-19, physicians say they have been whittling away at their backlogs and returning to the clinical

care they provided before the pandemic. It is too early to ascertain whether the delays in care caused

by the pandemic will adversely affect patient outcomes long-term, but physicians generally agree that

deferring prostate biopsies and de�nitive PCa treatment for a few months, at least for patients with

low-risk PCa, will not signi�cantly alter clinical outcomes. As healthcare services return to normal in

many places, the pandemic rages on in various regions of the United States as investigators work on

developing a COVID-19 vaccine and identifying safe and effective treatments.

References

1. COVID-19: Data. New York City Health Department website.

https://www1.nyc.gov/site/doh/covid/covid-19-data.page. Updated August 30, 2020. Accessed

August 31, 2020.

2. United States Washington Overview. Johns Hopkins University & Medicine Coronavirus

Resource Center website. https://coronavirus.jhu.edu/region/us/washington. Updated August

30, 2020. Accessed August 31, 2020.

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3. United States Oregon Overview. Johns Hopkins University & Medicine Coronavirus Resource

Center website. https://coronavirus.jhu.edu/region/us/oregon. Updated August 30, 2020.

Accessed August 31, 2020.

4. United States Florida Overview. Johns Hopkins University & Medicine Coronavirus Resource

Center website. https://coronavirus.jhu.edu/region/us/�orida. Updated August 30, 2020.

Accessed August 31, 2020.

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